Archive for the ‘Legislation’ Category

If you think about scope-of-practice creep at all, you may think immediately of the advocacy efforts so many physicians have made to preserve physician-led care and discourage independent practice by nurse anesthetists or physician assistants.

You may not have paid as much attention to the current momentum to grant independent practice to nurse practitioners, or NPs, nationwide.

In addition to the District of Columbia, 28 states allow NPs full practice authority to treat and prescribe without formal oversight. Half of these states grant NPs full practice authority as soon as they gain their licenses; the other half allow it after the NP practices with physician oversight for a period of time.

My home state, California, is one of the states that has always required physician oversight. Last fall, however, Governor Newsom signed a bill, Assembly Bill 890, that will allow NPs to practice independently after they have completed a three-year transition period, practicing under physician supervision.

That was when I started to worry.

Preop assessments that make us laugh or cry

No doubt everyone who practices anesthesiology or surgery has encountered preoperative medical assessments, H & Ps, or “clearance” notes that have been so far off the mark they’re laughable. I’m not just talking about the three-word “cleared for surgery” note scrawled on a prescription pad. I recall in particular:

A consultation at a VA hospital that “cleared” my cirrhotic patient with massive ascites and coagulopathy for his inguinal hernia repair under spinal anesthesia but not general.

A cardiologist who opined that my patient needed a permanent pacemaker, but it could wait until after his carotid endarterectomy because “this patient has a low risk of perioperative bradycardia. If he were to develop AV block intraoperatively, a temporary transvenous pacemaker could be placed.” (Wait. What? Carotid procedures are notorious for bradycardia. We’re going to insert a transvenous pacing wire through his open neck incision?)

An H & P from a community internist that “cleared” my patient with lung cancer for lobectomy so long as it could be done under local with sedation.

Then we have to deal with the widespread misconception that “minimally invasive” is synonymous with “trivial” when it comes to surgical procedures. My husband, Steven Haddy, MD, a cardiac anesthesiologist, loves to give a lecture to an internal medicine audience on pulmonary hypertension and anesthesia, and wait for the gasps when he shows the photo of a “minimally invasive” robotic prostatectomy with the robot docked, the abdomen insufflated, and the patient in steep Trendelenburg.

If non-anesthesiologist physicians can do such an inept job with preoperative assessments, what are we to expect from nurse practitioners?

What could go wrong?

I rely with complete confidence on the H & Ps of one experienced nurse practitioner who works in the office of a thoracic surgeon. She understands thoracic surgery procedures and their risks, knows the patients and their history, and orders exactly the right preoperative tests, every time.

What causes me anxiety, as an anesthesiologist, is thinking about the accuracy and thoroughness of a preoperative assessment I might receive from a primary care NP, working in an outpatient clinic with no physician consultation. In a brief H & P, we have no way to know what information may have been omitted. If there is little understanding of the surgery or the anesthetic impact of the patient’s underlying medical problems, how would that person know what’s important to include?

Currently, there are more than 290,000 licensed NPs in the US, and Becker’s Hospital Review reports that the number of FTEs surged 109% in the past decade. More than 30,000 NPs complete their academic programs each year.

Until I read the book, Patients at Risk, by Niran Al-Agba, MD, and Rebekah Bernard, MD, I had no idea how little breadth or depth there might be to a nurse practitioner’s education. “Registered nurses who already have a bachelor’s degree in nursing can become a Family Nurse Practitioner in under two years, with coursework completed entirely online,” the authors report. “Schools are now fiercely competing for students to fill their classrooms. One of the downsides of the increased capacity for students is that the criteria for entry have declined. In fact, at least nine programs boast 100% acceptance rates – every student who applies is guaranteed acceptance.”

Since nurse practitioners can earn higher pay than registered nurses, there is an ongoing exodus of RNs into NP programs. They have the option to select a patient population focus on acute care, either for adults or children. But most students – nearly 90%, according to the American Association of Nurse Practitioners (AANP) – certify in an area of primary care. Their certification exams are specific to primary care, and require no additional education or clinical precepting in perioperative care.

Protecting patients

If you already live in a state with full practice authority for NPs, then the camel – not just the camel’s nose – is already in the tent. There will be little you can do other than to have a low threshold for questioning the information, or lack of it, in a preop H & P generated by a non-physician you don’t know personally.

In California, though AB 890 has already passed, there is work to be done in terms of scrutinizing its language and guiding its implementation.

I find it discouraging that the law’s requirements (Section 4, Article 8.5) “are intended to ensure the new category of licensed nurse practitioners has the least [emphasis mine] restrictive amount of education, training, and testing necessary to ensure competent practice.”

I find it outright alarming that one of the conditions listed that would mandate referral to a physician is “any patient with acute decomposition [sic].” My hope would be that the patient would be referred to a higher level of care before decomposition started, but you never know.

To its credit, the California Medical Association (CMA) has established an AB 890 Task Force to provide “expertise and strategic advice” regarding the implementation of AB 890, and “to make recommendations relating to the education of NPs, patient access to care, and patient safety, among other topics.” I have the honor of representing anesthesiology on this task force, and will do my best to ensure that NP independent practice is never defined to include the practice of anesthesiology, perioperative medicine, or pain medicine.

This underscores the importance of having all physicians become members also of our state and county medical associations. If you don’t join, you won’t have a voice. There is always a need for guardrails and vigilance to ensure that everyone in healthcare – physicians and nurses alike – practices within the safe limits of their knowledge and training.

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An earlier version of this article appears in the April 2021 issue of the ASA Monitor.

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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We’re very fortunate in anesthesiology. We’re seldom the physicians who have to face families with the terrible news that a patient has died from a gunshot wound.

But all too often we’re right there in the operating room for the frantic attempts to repair the bullet hole in the heart before it stops beating, or the blast wound to the shattered liver before the patient bleeds to death.

Despite all the skills of everyone in the operating room – surgeons, anesthesiologists, nurses, technicians – and all the blood in the blood bank, we’re not always successful. A death on the OR table is a traumatic event and a defeat; we remember it decades later.

So yes, this is our lane too. Memories haunt me of the times when mine was the last voice a gunshot victim heard on this earth, telling him he was about to go to sleep as he went under anesthesia for the last-ditch, futile attempt to save him.

I use the pronoun “he” intentionally, as every one of those cases in my professional life has been a young man. My experience is representative; most gunshot victims aren’t the random targets of mass shootings. They are overwhelmingly male (89 percent), under the age of 30 (61 percent), and over half are from the lowest income quartile.

The National Rifle Association (NRA) is way off base in telling physicians to mind their own business as it did in its infamous November 7 tweet. Human life is our business. Pediatricians have every right to remind parents that gun security, and keeping guns out of the hands of children, are vital to their well-being right up there with getting them vaccinated.

At my house, we’ve always kept our guns padlocked in a safe that our children couldn’t have broken into with a crowbar. We’re not NRA members, but we enjoy going to a shooting range on occasion. I learned gun safety during my officer training in the Army Reserve Medical Corps. My husband and I are firmly in the category of gun-owners who take both the right and the responsibility with the utmost seriousness.

Physician opinions on gun control and gun ownership vary just as much as the opinions of the rest of the population. What doesn’t vary is our collective sense of responsibility for public health and our support for better, more readily available, mental health care.

The solutions to America’s horrific rate of gun-related deaths aren’t easy or obvious. But the NRA isn’t helping matters with its thoughtless and incendiary social media message.

When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

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